Topics in Geriatrics: Perturbation training for fall prevention
Perturbation training is an appropriate and effective intervention in decreasing the risk for falls in the older adult. The CDC reports that one out of three older adults fall each year, the resulting injuries from these falls are among the leading cause of death for the older adult. As a means of primary prevention perturbation training has been shown to decrease fall risks in the older adult as well as special populations with balance deficits such as people with Parkinson disease.
Objectives:
The objectives of this page are to: 1) Learn more about perturbation training. 2) Learn different methods used to provide perturbation training. 3) Learn about the evidence related to perturbation training as an intervention for falls in the older adult.
Information about perturbation training: What is perturbation training? Perturbation training is eliciting an involuntary compensatory postural response through a trigger such as a trip or a fall. The essential goal of perturbation training is to elicit a response that is not under the patients direct volitional control. There are several accepted methods used to provide perturbation training, the key methodology requires providing a sudden external perturbation with enough force to change the center of mass over the base of support. These external directed forces lead to activation of several recovery strategies that can be trained to improve balance recovery and reduce the risk for falls in the older adult.
How do I perform perturbation training? Several methods can be used to provide perturbation intervention. Mansfield et al used perturbation platform that moves unpredictably during standing and results in the patient having to compensate in order to avoid falling. The study performed this in multiple directions in order to achieve better gains for the older adult. Others have described other effective methods that require less instrumentation. Rogers et al showed that either voluntary or waist-pull while standing on a variety of surfaces could achieve a similar response. Both studies demonstrated increases in response time as well as improve stepping strategies in static positioning. Although these tests provided desirable results, they are limited by the lack of challenging dynamic recovery during functional movement. Further studies have implemented perturbation training during dynamic activities. Miziaszek and Krauss initiated manual perturbations in the sagittal plane with simultaneous use of a motorized treadmill. Perturbations were applied randomly to the pelvis and random times. Shimada et al also utilized a dynamic approach through using a split treadmill.Perturbations were provided through changing the speed of each individual belt to perturb normal gait. Both of these dynamic interventions seem to be more relevant to real life postural perturbations and responses. Results for both of these dynamic studies demonstrated a decreased fall risk for older adults.
Evidence for Use of perturbation based training: There is a high level of evidence for the use of perturbation training in the prevention of falls for the older adult. Pai YC et al performed a randomized control trial evaluating the effectiveness of perturbation training with a single session of repeated-slip recovery training. The results of the study demonstrated a decreased fall risk for older adults by 50%. The study evaluated 212 older adults and concluded that a single session of perturbation training “increases resilience to postural disturbances and significantly results in a decreased fall risk”. Mansfield et all additionally performed a systematic review and meta-analysis of preliminary randomized controlled trials. Eight studies with a total of 404 participants were evaluated, with both a control group and perturbation group. Results of the study showed a decreased fall risk for the perturbation group (overall risk ratio=0.71; 95% confidence interval=0.52, 0.96; P=.02) when compared to the control group ((overall rate ratio=0.54; 95% confidence interval=0.34, 0.85; P=.007)). The perturbation group additionally reported fewer falls when compared to the control group.
What population is appropriate for perturbation training? Perturbation training has been shown to be appropriate with a variety of patients and is not solely used in treatment with older adults with balance deficits. Mansfield et al performed a study that found perturbation therapy to be effective in the treatment of patients with Parkinson's disease. In younger populations rehabilitating from injury or looking to enhance sports related training, perturbation training has been used to enhance function. Additionally perturbation training extends past the spectrum of fall prevention for older adults, in reducing pain and improving function in patients with knee osteoarthritis.
Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ. Agility and Perturbation Training Techniques in Exercise Therapy for Reducing Pain and Improving Function in People With Knee Osteoarthritis: A Randomized Clinical Trial. Physical Therapy. 2011;91(4):452-469.
Rogers MW, Johnson ME, Martinez KM, Mille ML, Hedman LD: Step training improves the speed of voluntary step initiation in aging. J Gerontol A Biol Sci Med Sci 2003, 58(1):46-51
Shapiro A,Melzer I: Balance perturbation system to improve balance compensatory responses during walking in old persons.Journal of NeuroEngineering and Rehabilitation;volume 7
Mansfield A, Peters AL, Liu BA, Maki BE: A perturbation-based balance training program for older adults: study protocol for a randomized controlled trial. BMC Geriatr 2007
Misiaszek JE, Krauss EM: Restricting arm use enhances compensatory reactions of leg muscles during walking. Exp Brain Res 2005, 161:474-485
Shimada H, Obuchi S, Furuna T, Suzuki T: New intervention program for preventing falls among frail elderly people: the effects of perturbed walking exercise using a bilateral separated treadmill. Am J Phys Med Rehabil 2004, 83:493-499.
Pai YC, Bhatt T, Yang F, Wang E: Perturbation training can reduce community-dwelling older adults’ annual fall risk: a randomized controlled trial. J Geronotol A boil Sci Med Sci 2014 Dec;69(12):1586-94.
Perturbation training is an appropriate and effective intervention in decreasing the risk for falls in the older adult. The CDC reports that one out of three older adults fall each year, the resulting injuries from these falls are among the leading cause of death for the older adult. As a means of primary prevention perturbation training has been shown to decrease fall risks in the older adult as well as special populations with balance deficits such as people with Parkinson disease.
Objectives:
The objectives of this page are to:
1) Learn more about perturbation training.
2) Learn different methods used to provide perturbation training.
3) Learn about the evidence related to perturbation training as an intervention for falls in the older adult.
Information about perturbation training:
What is perturbation training?
Perturbation training is eliciting an involuntary compensatory postural response through a trigger such as a trip or a fall. The essential goal of perturbation training is to elicit a response that is not under the patients direct volitional control. There are several accepted methods used to provide perturbation training, the key methodology requires providing a sudden external perturbation with enough force to change the center of mass over the base of support. These external directed forces lead to activation of several recovery strategies that can be trained to improve balance recovery and reduce the risk for falls in the older adult.
How do I perform perturbation training?
Several methods can be used to provide perturbation intervention. Mansfield et al used perturbation platform that moves unpredictably during standing and results in the patient having to compensate in order to avoid falling. The study performed this in multiple directions in order to achieve better gains for the older adult. Others have described other effective methods that require less instrumentation. Rogers et al showed that either voluntary or waist-pull while standing on a variety of surfaces could achieve a similar response. Both studies demonstrated increases in response time as well as improve stepping strategies in static positioning. Although these tests provided desirable results, they are limited by the lack of challenging dynamic recovery during functional movement. Further studies have implemented perturbation training during dynamic activities. Miziaszek and Krauss initiated manual perturbations in the sagittal plane with simultaneous use of a motorized treadmill. Perturbations were applied randomly to the pelvis and random times. Shimada et al also utilized a dynamic approach through using a split treadmill.Perturbations were provided through changing the speed of each individual belt to perturb normal gait. Both of these dynamic interventions seem to be more relevant to real life postural perturbations and responses. Results for both of these dynamic studies demonstrated a decreased fall risk for older adults.
Evidence for Use of perturbation based training:
There is a high level of evidence for the use of perturbation training in the prevention of falls for the older adult. Pai YC et al performed a randomized control trial evaluating the effectiveness of perturbation training with a single session of repeated-slip recovery training. The results of the study demonstrated a decreased fall risk for older adults by 50%. The study evaluated 212 older adults and concluded that a single session of perturbation training “increases resilience to postural disturbances and significantly results in a decreased fall risk”. Mansfield et all additionally performed a systematic review and meta-analysis of preliminary randomized controlled trials. Eight studies with a total of 404 participants were evaluated, with both a control group and perturbation group. Results of the study showed a decreased fall risk for the perturbation group (overall risk ratio=0.71; 95% confidence interval=0.52, 0.96; P=.02) when compared to the control group ((overall rate ratio=0.54; 95% confidence interval=0.34, 0.85; P=.007)). The perturbation group additionally reported fewer falls when compared to the control group.
What population is appropriate for perturbation training?
Perturbation training has been shown to be appropriate with a variety of patients and is not solely used in treatment with older adults with balance deficits. Mansfield et al performed a study that found perturbation therapy to be effective in the treatment of patients with Parkinson's disease. In younger populations rehabilitating from injury or looking to enhance sports related training, perturbation training has been used to enhance function. Additionally perturbation training extends past the spectrum of fall prevention for older adults, in reducing pain and improving function in patients with knee osteoarthritis.
Resources:
Management of knee OA: Evidence based exercise progression is available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070919/
Training for younger or athletic population: http://www.sportsmd.com/performance/training-agility-perturbationbalance/
References